Doctor Name: _____________________________________ Date: _________________

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PRECISION DENTAL ARTS
Excellence in Dental Prosthetics
440-835-2541
24600 Detroit Rd. Suite 201, Westlake, Oh 44145
Case Notes
Doctor Name _____________________________________
Date _________________ Signature___________
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____ License ___________________________
Phone ( ) ______-_________________


Pre-Scheduled City _______________ State
______ Zip _______ Due Date
____________________ Email ____________________
_____________ Preferred Communication Email
Phone
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___________________________________________ ______
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___________________________________ Materials
Sent Impression(s) Bite Record Study
Models Opposing Model
Shade Tab Photos / Card E-mail X-rays
Dicom Data Implant
Analog Implant Abutment(s) Intra Oral
Scan Scan Bodies Used ___________________________
____________________ Lab Please Call to Discuss
Please
Send Overall Case Materials
Esthetics Occlusion Boxes
Prescriptions Other _________________________
_______________
Patient Name _______________________________
_________ Male Female
Age ____________ Adjacent Restorations
Present Yes ___ No ___ Adjacent Tooth s
Restored _______________ Restorative
Material Used __________________
Pre-Op Shade ________________
Requested Shade ________________
Prep Shade ________________
All teeth same Pt. Bleaching
color and value Gradient of color
Occl. Stain - - - - - - - - - - -
- - - - - - - - - - - - - Shade Diagram
Send Photos to photos_at_precisiondentalarts.com
Implants placed by _____________________________
____________________ Implant Brand
___________________ Implant Sizes
____________________ Implant Site s
____________________ Abutment Preferred Technician
s Preference Y___ N___ USE OEM PARTS ONLY
Y___ N____ Stock Titanium ___ Zirconia
___ Custom Cast ____ Titanium _____ Zirconia
___ Milled Titanium ____ Shaded
Titanium____ Hybrid Pressed with Ti Interface
_____ Milled Zirconia with
Ti Interface_____
One Piece Screw Retained _______
Abutment Margin Design
Diagnostic Wax-Up Total Units
________________ Veneer Teeth s
____________ Crown Teeth s
_____________ Onlay-Veneer s
____________ Posterior-Teeth s
_____________ Duplicate Silicone Index
Copyplast Provisional Restorations Total
Units ________________ Crown Tooth s
_____________ Anterior Restorations Total
Units ________________ Layered Tooth s
____________ Stained Only Tooth s
_____________ Posterior Restorations
Total Units ______________ Layered
Tooth s __________ Stained Only Tooth
s ____________ Bridge Pontic Design
Ovate Adjust Ridge Accordingly
Ridge Lap No Ridge Adjustments
Depth
Mesial
Facial
Lingual
Distal
Technicians Preference Y___ N____ Metal Ceramic
(PFM) Tooth s_________________
Alloy Selection High
Noble White Yellow
Noble White
Metal-Ceramic Junction ________ mm Metal
Lingual Collar Only 3600 Metal Margin
Porcelain Butt Margin Y___ N___ All Ceramic
Tooth s ________________
Empress E-Max
Full Contour Zirconia Layered Zirconia
Enamic
Feldspathic Full Cast Crown/Onlay
Tooth s ________________
Emergence
Full Contour
Moderate Displacement
No Tissue Displacement
___ Make Custom Incisal Guide Table From
Pre_Op Casts Provisional
Casts ___ Develop Anterior Guidance (Cuspid) ___
Develop Group Function ___ Open Vertical
Dimension by ______ mm IF NOT ENOUGH RESTORATIVE
ROOM ___ Adjust Opposing Teeth ___ Adjust
Preparation
Abutment Surface Micro Etched ___ Polished ___
Margin Type Shoulder ____ Chamfer _____
Depth _______ mm
Lab use only Alloy_______ Weight_____ dwt
Ingot_____ CAM_____ Pre-Scheduled Yes___ No____
Waranteed Yes___ No____
Code_______ YZ_______ 2 0 _________
2
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3
INSERT FACIAL PHOTOS HERE
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4
INSERT RADIOGRAPHY HERE
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5
IMPORT TRIOS SCAN FILE HERE
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